Stuart Youngner

Globally, efforts to increase organ supply have included increasing the numbers of living organ donors. A 2009 study of living kidney donation indicated a growth rate of 50% or more over the last decade more in 62% of the 69 countries studied, with almost 40% of all kidney transplants worldwide coming from live donors by 2006 (Horvatt, Shariff, and Garg, 2009). In the U.S., the numbers of living organ donors actually surpassed those of deceased donors over a three year period from 2001-2003 and growth in living donation outpaced that of deceased donation by more than 3-2 from 1996 to 2005 (www.optn.org/latestData/rptData.asp). This growth raises a number of ethical questions. This chapter (1) identifies and articulates ethical challenges for living organ donation in the U.S., (2) offers suggestions for meeting these challenges, and (3) sounds a call for international dialogue as these ethical issues are without national or international borders.

When scholars grant wisdom to their own emotions, they become advocates (political or religious) pushing some cause or another. Dr. Mills gives us no way of deciding which emotions should be given prominence in moral decision-making. When she touts her own favourite form of repugnance (against state-sponsored torture) without argument, she abandons her role as scholar. Dr. Ikeda goes too far when he seems to equate the mental abilities of people with Down’s Syndrome with those of chimpanzees. Certainly, many of the former outperform all of the latter when it comes to intelligence, compassion, and social sophistication. PVS or anencephaly would make better examples than Down’s Syndrome for the argument Ikeda wishes to make.

This exploration of the origin and meaning of moral boundaries in bioethics asks questions such as: by what authority and methodology are boundaries created, identified, and defended; what could motivate one to cross a moral boundary; what could motivate one to protect a moral boundary? Examples of moral boundaries include: human/animal; male/female; life/death; killing/allowing to die; and natural/unnatural. This chapter focuses on species boundaries, particularly the boundary between humans and animals in the creation of chimeras for research purposes. It concludes that in modern, pluralistic society, religious dictates, the so-called “wisdom of repugnance” and simple resistance to change must be taken into account in the political sphere, but have little to offer to a rational discussion and resolution of the issues.

Mandating psychiatric evaluation for patients who request physician‐assisted suicide may not offer the clearcut protection from possible coercion or other abuse that proponents assert. Competence itself is a complex concept and determinations of decisionmaking capacity are not straightforward, nor is the relationship between mental illness and decisionmaking capacity in dying patients clearly understood. And casting psychiatrists as gatekeepers in end‐of‐life decisions poses risks to the profession itself.

Over the past decade, public discussion has focused on the ethics of issuing Do‐Not‐Resuscitate Orders, and the failure of many hospitals to acknowledge their actions openly. Recent efforts on the part of some hospitals to establish formal DNR guidelines that are prudent, fair, and humane, are a helpful beginning, though they cannot account for all the vagaries of illness and human communication. But concerns about DNR should not divert us from looking closely and rigorously at other, more common treatment/nontreatment decisions in the critical care setting.

This study examined health professionals’ (HPs) experience, beliefs and attitudes towards brain death (BD) and two types of donation after circulatory death (DCD)—controlled and uncontrolled DCD. Five hundred and eighty-seven HPs likely to be involved in the process of organ procurement were interviewed in 14 hospitals with transplant programs in France, Spain and the US. Three potential donation scenarios—BD, uncontrolled DCD and controlled DCD—were presented to study subjects during individual face-to-face interviews. Our study has two main findings: (1) In the context of organ procurement, HPs believe that BD is a more reliable standard for determining death than circulatory death, and (2) While the vast majority of HPs consider it morally acceptable to retrieve organs from brain-dead donors, retrieving organs from DCD patients is much more controversial. We offer the following possible explanations. DCD introduces new conditions that deviate from standard medical practice, allow procurement of organs when donors’ loss of circulatory function could be reversed, and raises questions about “death” as a unified concept. Our results suggest that, for many HPs, these concerns seem related in part to the fact that a rigorous brain examination is neither clinically performed nor legally required in DCD. Their discomfort could also come from a belief that irreversible loss of circulatory function has not been adequately demonstrated. If DCD protocols are to achieve their full potential for increasing organ supply, the sources of HPs’ discomfort must be further identified and addressed

The ever‐increasing demand for organs led Spain, France, and other European countries to promote uncontrolled donation after circulatory determination of death (uDCDD). For the same reason, New York City has recently developed its own uDCDD protocol, which differs from European programs in some key ways. The New York protocol incorporates a series of technical and management improvements that address some practical problems identified in response to European uDCDD protocols. However, the more fundamental issue of whether uDCDD donors are dead when organs are procured remains problematic for the New York City protocol and, indeed, for all uDCDD protocols. In the United States, two amendments to the legal criteria of death have been suggested to avoid a formal violation of the dead donor rule in DCDD protocols: first, replacing the requirement “irreversible” with the weaker term “permanent,” and second, using the term “circulatory” instead of “cardiac” to identify the key function that must be lost to declare death. While intended to facilitate controlled DCDD, these modifications create a problem for uDCDD protocols: if extracorporeal membrane oxygenation is introduced to preserve the organs, then circulation is restored after death is declared. In this issue of the Hastings Center Report, Kevin Munjal and colleagues call for a new ethical construct and policy so that uncontrolled and controlled DCDD can coexist.

Clinical ethics consultation is largely outside the scope of regulation and oversight, despite its importance. For decades, the bioethics community has been unable to reach a consensus on whether there should be accountability in this work, as there is for other clinical activities that influence the care of patients. The American Society for Bioethics and Humanities, the primary society of bioethicists and scholars in the medical humanities and the organizational home for individuals who perform CEC in the United States, has initiated a two‐step quality attestation process as a means to assess clinical ethics consultants and help identify individuals who are qualified to perform this role. This article describes the process.

This handbook explores the topic of death and dying from the late twentieth to the early twenty-first centuries, with particular emphasis on the United States. In this period, technology has radically changed medical practices and the way we die as structures of power have been reshaped by the rights claims of African Americans, women, gays, students, and, most relevant here, patients. Respecting patients’ values has been recognized as the essential moral component of clinical decision making. Technology’s promise has been seen to have a dark side: it prolongs the dying process. For the first time in history, human beings have the ability to control the timing of death. With this ability comes a responsibility that is awesome and inescapable. How we understand and manage this responsibility is the theme of this volume. The book has six sections. Section I examines how the law has helped shape clinical practice, emphasizing the roles of rights and patient autonomy. Section II focuses on specific clinical issues, including death and dying in children, continuous sedation as a way to relieve suffering at the end of life, and the problem of prognostication in patients who are thought to be dying. Section III considers psychosocial and cultural issues. Section IV discusses death and dying among various vulnerable populations, such as the elderly and persons with disabilities. Section V deals with physician-assisted suicide and active euthanasia. Finally, Section VI looks at hospice and palliative care as ways to address the psychosocial and ethical problems of death and dying.

Alireza Bagheri supports a policy on organ procurement where individuals could choose their own definition of death between two or more socially accepted alternatives. First, we claim that such a policy, without any criterion to distinguish accepted from acceptable definitions, easily leads to the slippery slope that Bagheri tries to avoid. Second, we suggest that a public discussion about the circumstances under which the dead donor rule could be violated is more productive of social trust than constantly moving the line between life and death.

Many critics of the legalization of physician‐assisted death oppose it in part because they fear it will further disadvantage those who are already economically disadvantaged. This argument points to a serious problem of how economic considerations can influence medical decisions, but in the context of PAD, the concern is not borne out. We will provide empirical evidence suggesting that concerns about money influence medical decisions throughout the full course of illness, but at the end of life, financial pressure is much more likely to influence a decision to pursue or reject aggressive life‐extending care than it is to influence a request for PAD. We will also address the question of whether financial pressure as a result of being poor—particularly in the context of an inadequate social safety net—robs people of their autonomy, rendering their informed request and consent invalid. We argue that it does not. We will emphasize the impracticality and injustice of rejecting the role of poverty as a legitimate factor in decision‐making, the irrational distinction between PAD and withdrawal of life‐sustaining care, and the more appropriate focus on the great flaws in the American health care system.

In 1989, Susan Wolf convincingly warned of a troublesome consequence that should discourage any movement in American society towards physician-assisted death—a legal backlash against the gains made for limiting life-sustaining treatment. The authors demonstrate that this dire consequence did not come to pass. As physician-assisted suicide gains a foothold in USA and elsewhere, many other slippery slope arguments are being put forward. Although many of these speculations should be taken seriously, they do not justify halting the new practice. Instead, our courts, regulatory agencies, journalists, professional organisations and researchers should carefully monitor and study it as it unfolds, allowing continuous improvement just as our society has done in implementing the practice of limiting life-sustaining treatment.

There are two recent important studies of public knowledge about brain death and its relationship to organ procurement. The first is a comprehensive review of studies that have been conducted in several countries.1 The second is arguably the most thoughtful and comprehensive survey to date.2 The authors of both studies call for more study, education and engagement with the public. Transparency during the process would remove the fig leaf that has covered the fictions and inconsistencies concerning brain death. While public engagement and transparency are generally a good idea, there are some caveats. I will focus on two of them. The first caveat has to do with the limitations of education and discussion that have been imposed by our grossly oversimplified language about death. Alan Shewmon has written eloquently about this issue: ‘The lexicon of any culture or society reflects what it values’3 (p279); ‘Pilots and weathercasters, for …